Originally published in The Ottawa Citizen March 11, 2005

The thrill of the winter sojourn to warmer climes and ocean activities like scuba diving, surfing and snorkeling, among others, can lead many to overlook other notable health and safety precautions.

If you’re heading south for some fun in the surf, remember the ocean is an alien world with creatures that, for all their beauty, can be a literal shock to the system.

What do you do when stung by a jellyfish, step on a sea urchin’s spine, encounter the whip of a stingray’s tail, or eat a poisonous fish?

Certain reef fish like grouper, king mackerel, sturgeon and snapper can ingest microscopic organisms called dinoflagellates either directly or by eating smaller fish. One particular species, gambierdiscus toxicus, produces a toxin that becomes increasingly concentrated as it travels up the food chain.

Thousands of people eating these fish found around Hawaii, Florida, Puerto Rico and the U.S. Virgin Islands can develop Ciguatera (seeg-wha-terra) poisoning. The severity of poisoning depends on the fish size and the number of exposures. The classic symptom found in 80 per cent of patients is a cold sensation reversal, where hot sensations are perceived as cold and vice versa.

Gastrointestinal and neurological symptoms usually begin one to six hours after ingestion and last seven to 14 days, and in some cases months to years. They include nausea, vomiting, watery diarrhea, abdominal pain, numbness, vertigo, severe weakness, muscle aches, slowed heart rate (bradycardia), low blood pressure (hypotension), diffuse pain and decreased vibration and pain sensations.

There is no immediate cure, only symptom relief. Cooking, freezing, salting or smoking the fish does not deactivate the toxin. If these fish are eaten, avoiding eating the fish’s internal organs like the liver because the toxin concentrates in these areas.

Travellers to Hawaii and California who eat tuna or mackerel may develop scombroid. Poor handling and refrigeration of the fish can cause a buildup of histamine and histamine-like substances within the dark meat. The person develops symptoms 30 minutes after ingestion. Symptoms can last about eight hours and include flushing, nausea, vomiting, diarrhea, severe headache, palpitations, abdominal cramping, dizziness, dry mouth, hives, and red eyes.

Treatment includes the use of antihistamines administered by mouth, intravenous or into the muscle, depending on symptom severity.

Encounters with jellyfish are memorable. Their long tentacles have stinging cells, or nematocysts, that sting. Nematocysts found on amputated tentacles and dead jellyfish will sting as well.

Symptom severity depends on the number of stinging nematocysts, the toxicity of the venom and each person’s unique reaction. The poison is destructive; it damages skin, red blood cells, heart tissue and nerves.

The most common symptom is local pain followed (in order or likelihood) by a “pins and needles” feeling (paresthesias), nausea, headache, chills and, rarely, cardiovascular collapse or shock. Symptoms can last up to three days.

Treatment focuses on pain relief and controlling neurologic symptoms. Use gloves or forceps to remove any visible tentacles. Avoid touching towels used to wipe off the nematocysts; they will sting. A 30-minute application of vinegar (five per cent acetic acid) will stop any remaining nematocysts on the skin from releasing their venom. Salt water is a good substitute if vinegar is unavailable. Never use fresh water because it will stimulate venom release.

Scraping the nematocysts off the skin using shaving cream and a razor is another solution. There are reports that cold and hot packs can help sooth the pain.

Stepping on a sea urchins’ toxin-coated spines will cause pain and burning and occasional skin discolouration lasting about 48 hours. The spines will break if you try to remove them by hand. Fragments will remain embedded in the skin and can cause infection. Surgical removal and wound debridement may be necessary.

The stingray’s venomous spine is at the end of its tail. The venom will reduce blood flow to the affected limb causing tissue death and destruction, poor wound healing and infection.

Intense pain is immediate and can be accompanied by salivation, nausea, vomiting, diarrhea, muscle cramps, shortness of breath, seizures, headaches, muscle cramp and cardiac arrhythmias. Fatalities are rare.

Bleeding from the puncture site is controlled by direct pressure to the wound. Hot water soaks will help reduce the pain.

Wound care includes thorough rinsing of the affected area with fresh water. Patients should check for redness and swelling at the site; a sign of infection. Sometimes, part of the spine will remain embedded in the tissue; surgical removal may be necessary.

A tetanus shot may be required for stingray and sea urchin stings. Although fatalities are rare for all these toxic reactions, prompt recognition of the symptoms can lessen the discomfort and morbidity.

© Dr. Barry Dworkin 2005

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Originally published in The Ottawa Citizen October 12, 2004
Original Title: Out, Out Damn Spot Part Two

On Oct. 3, I reviewed why hyperpigmentation (dark skin spots) occurs, as well as some of the common causes and conditions. But it does not end there. Indeed, there are more skin conditions that raise many questions from concerned patients.

At the forefront in many people’s minds is whether a dark spot could be melanoma. Even with the increase in sunscreen use, the incidence of melanoma continues to grow. Early detection is vital to curing this disease.

If you are concerned about the appearance of a mole on your skin, the following “A-B-C-D-E” criteria for melanoma risk may be helpful:

Asymmetry: If the mole is divided in half by an imaginary line, both halves should appear identical for a non-cancerous (benign) mole.

Borders: The benign mole is usually round, having sharp, well-defined margins. A ragged, blurred, notched or uneven border is not normal.

Colour: A mole having a homogenous brown colour is normal. Multishaded moles or those that have a combination of colours such as blue, purple, red or black are suspicious for cancerous change.

Diameter: Moles greater than six millimetres (quarter inch) in diameter, about the size of a pencil eraser, are suggestive of melanoma.

Enlargement: A recent increase in the size of the mole warrants further investigation.

Any abnormal finding should be seen by your doctor.

Some may notice new skin growths that look like old bubblegum stuck onto the skin. They can be dark brown or black to tan in colour, have sharp borders and a surface that can be rough and craggy or smooth and pearly. These are seborrheic keratoses and are painless, benign and occur mostly in mid- to late-adult life. Removal is usually for cosmetic reasons unless it is rubbing on clothing, undergarments or other high-friction areas.

Obesity, Cushing’s syndrome, hypothyroidism and Type 2 diabetes, among other conditions, can lead to the development of small dark skin growths called acanthosis nigricans (Latin: dark thorn) in the skin folds of the neck, in the armpit, under the breast, in the groin or under the belt line. They can appear thick, leathery and wart-like, or a velvety brown streaking on the skin. The thick lesions can accumulate bacteria and give off a foul odour. A skin biopsy can confirm the diagnosis.

When acanthosis nigricans rapidly appears on the palms or soles of a non-diabetic patient, it may indicate that a cancerous tumour is growing somewhere. A thorough investigation will help determine if cancer is present. Most of these tumours (in order of incidence) are found in the stomach, colon, ovary, pancreas, rectum and uterus.

Treatment of acanthosis nigricans is directed at the underlying disease that initially led to the skin changes. If present, insulin resistance should be managed appropriately. Weight reduction will help eliminate the skin discolouration and improve the control of diabetes. Thick lesions with a bad odour can be cleaned with antibacterial soaps.

Diabetics can also develop a pimply pink or brown area called diabetic dermopathy. It will progress to a flat brown skin swelling that appears on the shins about 70 per cent of the time. Good sugar control can lead to their disappearance. Sometimes they do resolve spontaneously.

Darkening of the facial skin or melasma is distressing to many people. Certain hormonal medications, pheytoin (dilantin) and pregnancy can cause melasma by stimulating the skin to produce more pigment cells or melanocytes.

Treatment of melasma includes vitamin A acid creams, bleaching agents such as hydroquinone in combination with topical steroid creams and laser therapy. Avoidance of sun exposure can help prevent recurrence. Treatment success is variable and should be reviewed with your doctor.

Injured or traumatized skin can become more sensitive to pigment changes. The physical or chemical damage can cause a darkening or lightening of the skin. Indeed, exposing damaged skin to the sun can result in a permanent tanned patch.

The best advice is to talk to your doctor about any concerns you may have about skin discoloration. A general rule is the earlier it is assessed, the better the outcome.

© Dr. Barry Dworkin 2004

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Originally published in The Ottawa Citizen October 3, 2004
Original title: Out, Out Damn Spot: Part 1

The formation of dark skin spots, or hyperpigmentation, can either be a benign condition or the development of a serious local or systemic disease.

In this two-part series, we will look at the causes and types of hyperpigmented skin changes.

Our skin contains pigment cells called melanocytes. These cells contain a tiny organ, the melanosome, which produces a pigment (melanin). Interestingly, the concentration of melanocytes in the skin of all races is the same. The skin colour is proportional to the number and size of melanosomes within each melanocyte.

Hormonal effects and skin irritation can increase the number of melanosomes within the cell, leading to darker skin. Sun exposure and certain diseases will increase the number of melanocytes, resulting in tanning or localized dark skin patches.

The diagnosis of these colour changes depends on three mechanisms: an increase in pigment cell numbers, an increase in melanin, or the laying down of another substance that darkens the skin.

A detailed history and physical exam will offer clues. Your doctor will want to know when the pigment changes started. Was it a birthmark? Did it develop during pregnancy or during childhood? Are there other physical symptoms and/or existing illnesses? Is the patient taking medications, herbal preparations or supplements? Has there been any recent exposure to new plants or ultraviolet (UV) radiation? These and other questions such as the colour, number and size of lesions help make the diagnosis.

What are some of the common hyperpigmented skin conditions?

Cafe au lait spots appear mainly on the trunk with a smooth or irregular border and bear the colour of coffee with milk. These lesions can be congenital (develop during fetal growth) or appear during childhood. The size varies from two millimetres to four centimetres in infants, and to 30 centimetres in adults. They are caused by increased melanin production.

The significance of this lesion is that it may be a sign (but in itself is not diagnostic) of neurofibromatosis (the Elephant Man’s disease). Removal of the lesions is unnecessary unless it is for cosmetic concerns.

Certain disease states like hyperthyroidism, Addison’s disease or hemochromatosis can increase the production of melanin. The hormonal imbalances from the former two conditions stimulate this effect. Although the pigment changes occur all over the body there seems to be a predilection for sun-exposed areas, the perineum (skin between the anus and genitals), armpits, areolas (dark skin around the nipple), palms and soles. Appropriate treatment will stop the pigment changes.

Seventy per cent of people with hemochromatosis, a disease that causes abnormally elevated blood iron levels, will develop a slate-grey skin colour change. It can stimulate an increase in melanin production that bronzes the skin. Treatment by phlebotomy (blood-letting) controls this disorder.

Ultraviolet light from the sun or tanning beds will also stimulate melanin production. However, some people may develop freckles (ephelides) about three millimetres in diameter on sun-exposed areas.

This is in contrast with tan- to dark-brown “mole-like” spots called lentigines that can appear all over the body. Lentigines measure about two to 20 millimetres and are not dependent on sun exposure. Both lentigines and freckles are benign and do not require any treatment.

Sunscreens and covering up in the sun will decrease the formation of more freckles. There are bleaching ointments and creams like hydroquinine to treat them. Some opt for laser therapy or peeling agents provided by a specialized treatment centre and physician.

Certain foods, medications and plants in combination with sun exposure can cause hyperpigmentation. Some of the plants and foods that cause these changes include carrot juice, fig leaves or stems, celery, dill, parsnips, lemons and limes.

These phototoxic reactions initially cause the skin to turn red, swell and blister in some people. Once this reaction calms, the melanocytes take over and overproduce pigment. Some medications can directly stimulate skin pigment production.

The descriptions and treatments of the hyperpigmented lesions are only to be used as a guide. Your doctor will be able to assess any additional implications of these conditions.

Next week: Part 2 will cover melanoma, diabetic skin changes and other common spots that seem to sprout as we age.

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Originally published in the Ottawa Citizen in April 2004

Alopecia or hair loss is a distressing turn of events for women. The scalp is often afflicted but it can occur on any part of the body. Why does this happen? Are there different types of hair loss?

Our hair follicles perpetually cycle through a growth and resting phase. The growth phase is called anagen, the resting phase, telogen and the time in between the two as the follicle shuts down for a rest, catagen.

Alopecia occurs through a disruption of either the follicle’s normal cycle or by damage to the follicle itself.  The evaluation of hair loss always begins with a complete medical history and physical exam.

You can assist your doctor by noting the duration and pattern of the hair loss. Are the hairs broken or shed at the roots?  Has the hair loss increased recently? Do you have a family history of alopecia?

The “pull test” defines normal shedding of the hair. Grasp about 60 hairs between the thumb and index and middle fingers. Pull them gently and but hold them firmly. Six or fewer hairs left between your fingers are considered normal shedding.

The most common type of hair loss in men and women is androgenic alopecia. Each hair follicle has androgen (male hormone) receptors. Activation of these receptors by the hormone dihydrotestosterone (DHT) shortens the anagen phase. The hair follicles will shrink. With each cycle the hair becomes thinner and the follicle smaller. In women the thinning occurs over the entire scalp but is most pronounced at the crown of the head and areas toward the forehead.

Women with androgenic alopecia do not have greater levels of androgens. Indeed, most have normal menstrual cycles, fertility and hormonal function. What has been found is that these women have greater levels of an enzyme that converts their normal levels of testosterone into DHT, lower levels of an enzyme that converts testosterone into estrogen and more androgen receptors in the hair follicle itself. All these factors add up to more hair loss.

The medication recommended to treat androgenic alopecia in women is minoxidil (Rogaine). It works by increasing the anagen phase, activates follicles stuck in the catagen phase and enlarges the hair follicles.

One clinical trial demonstrated minimal hair regrowth in 50 per cent of women and moderate regrowth in 13 per cent. Other trials demonstrated improved hair regrowth.

Alopecia areata can appear as the sudden appearance of one to two centimeter round shiny bald patches on the scalp. It occurs in two percent of the population equally affecting males and females. It is more common in children and young adults. The body’s immune system attacks the hair follicles for unknown reasons. Some people can experience complete loss of scalp hair.

Some people with thyroid disease, eczema or vitiligo (loss of skin pigmentation) will express this condition but most afflicted people are healthy.

Treatment options include local steroid injections into the bald spot, steroid creams, anthralin and minoxidil. Unfortunately, they are not completely effective. However, the condition will spontaneously resolve and recur.

Emotional and physical stressors can cause sudden non-permanent hair loss called telogen effluvium. Women will notice a lot more hair on their hairbrush or shower floor. Some will experience hair loss after pregnancy or from certain medications.

Telogen effluvium occurs when a great number of hair follicles become inactivated or enter the telogen phase. The follicles will enter anagen phase one to two months after the end of the stressful event.

Traumatic alopecia is due to certain hair styling practices. Tight braiding and repeatedly twisting and tugging the hair can cause the hair to fall out.

Hair loss does not occur with frequent shampooing and conditioning. Having your hair styled, coloured, teased, sprayed or permed will not worsen hair loss.

If you suspect hair loss, consult your doctor sooner rather than later.

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Originally published in The Ottawa Citizen February 29, 2004
Originally titled: “Common Skin Infections”

Bacterial skin infections are a common reason why people consult their family doctor. Each infection has its own specific treatment.

Cellulitis is a common and potentially serious skin infection that normally starts in areas where there is pre-existing skin damage. The skin becomes swollen, red and hot and has a poorly defined border. The area of redness (erythema) rapidly expands and creeps along the skin within hours.

Breaks in the top skin layer (epidermis) from cuts, surgical wounds, ulcerations or sores, crush injuries and fungal infections leave the underlying skin surface (dermis) vulnerable to bacterial infection. Group A streptococcus and staphylococcus aureus reside on the skin surface and protect it from other, more harmful bacteria. However, should these bacteria migrate under the skin, they can cause considerable damage.

Cellulitis commonly occurs on the fingers and legs. Other regions include the face, feet, hands, torso, neck, buttocks and normal appearing skin.

Bacteria can also spread under the skin through the lymphatic channels. These channels are designed to return excess tissue fluid (lymph) back into the blood stream. This “tracking” appears as red streaky lines about half a centimetre wide, emanating from the infection site, and helps diagnose cellulitis.

If diagnosed early, treatment consists of an oral antibiotic. Intravenous antibiotics are used if oral treatment fails or if there is an initial extensive spread of the infection. Diabetics and people with compromised immune systems may require more aggressive treatments. Most infections respond within 24 hours but it may take up to three days for some who require intravenous antibiotics.

Periorbital (around the orbit of the eye) cellulitis is treated with oral antibiotics, hot compresses and close physician follow-up. Children who develop this infection often have a bacterial sinus infection. Should this infection work its way inward into the orbit, it can cause severe eye damage, an emergency requiring an assessment by an ophthalmologist.

St. Anthony’s fire or erysipelas is an angry red infection caused almost exclusively by beta-hemolytic streptococcus. Flu-like symptoms can occur prior to the infection’s appearance. The infected area has well-defined sharp raised borders. Tracking may be seen as well. Unlike cellulitis, most cases occur on normal intact skin, particularly on the legs and face. The incidence of erysipelas continues to increase. Young children, the elderly, persons with diabetes, alcoholics and immuno-compromised patients seem to be the groups most affected.

Impetigo is the “day care/child care infection.” It is contagious and easily spread by skin-to-skin contact. Children two to five years of age are the most likely to develop impetigo on wounds, cold sores and on cracked skin overlying the corners of the mouth. There are two types of impetigo: bullous (large blisters) and nonbullous. The latter type is seen most often and is caused by staphylococcus aureus and group A streptococcus. Small solitary or clustered sores, or pus-filled tiny blisters or vesicles, appear with honey-yellow fluid oozing from them. The fluid dries, forming a crust over the wound.

Bullous impetigo, a staphylococcus aureus-mediated infection, appears as two- to five- centimetre balloon-like blisters containing thin yellow fluid. The blister often ruptures and exposes a bare pink area of skin. A particular strain of staphylococcus aureus can produce a toxin causing a large area of the top skin layer to peel away. The infected area resembles a hot water burn, hence the name Scalded Skin Syndrome.

For single eruptions or small clusters of impetigo, topical application of the antibiotic creams mupirocin (Bactroban) or fucidic acid (Fucidin) can control and cure the outbreak. When washing the skin, do not vigorously rub or scrub it because it can spread the infection. Extensively spreading impetigo requires an oral antibiotic. Recurrent impetigo occurs on people who tend carry staphylococcus aureus in their nose. This carrier state can be reduced by the topical application of mupirocin twice daily for five days.

Skin abscesses or furuncles appear as painful red pus-filled masses arising from a hair follicle. They can appear anywhere on the body, especially on areas exposed to friction. Furuncles rarely appear before puberty. They typically break open on the skin surface, allowing the pus to drain from the wound. Application of hot compresses and topical antibiotics such as Fucidin or Bactroban can help the healing. Furuncles can also heal spontaneously or your doctor may have to incise it allowing it to drain and heal.

Clusters of furuncles (carbuncles) can form painful, large, swollen, red and deep abscesses that open and drain onto the skin surface. Fever and malaise may occur with these lesions.

Treatment usually consists of incision and drainage. The honeycombed pus-filled spaces within the carbuncle are broken down with an instrument called a hemostat. The open wound is packed with a sterile gauze strip to allow the wound to drain. Oral antibiotics are used for severe infections.

Prompt assessment by your doctor can help prevent the more severe forms of these infections. Consult your doctor if your are unsure what to do next.

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Originally published in The Ottawa Citizen February 12, 2004
Original Title: A Burning Issue

Many people are unaware of the proper management of burns. Is there a need to apply creams, antibiotics, salves or natural products to promote healing? What are the first steps to prevent or minimize skin damage in the immediate aftermath of a burn?

An understanding of burns begins with a review of the four layers of the skin: the epidermis, dermis, subcutaneous (tissue under the dermis), and muscle.

The epidermis is the tough skin surface and our protective barrier against disease and the elements. The dermis resides under the epidermis and holds the small arteries, veins, sweat glands and hair follicles. The subcutaneous layer contains fat and more blood vessels. The muscle is the deepest layer.

Immediate treatment of mild to moderate burns is vital to lessen the damage. The treatment of severe burns is beyond the scope of this column.

Burn severity and its potential complications relies on the depth of skin damage, the percentage of burned body surface area, the burn mechanism (e.g. hot sticky tar versus a flash flame) and the area affected (face, hands, eyes, genitals, etc). In addition to fire and heat, radiation, electricity, chemicals and sunlight are other causes of burns.

Thin or superficial burns (first-degree burns) are red and painful. The skin may be slightly swollen and turns white (blanches) if you press on it. Damage is limited to the epidermal layer and the skin may peel away a few days after the burn. It usually heals within three to six days.

Second-degree burns cause blisters and are painful. There are two subcategories: superficial partial-thickness and deep partial-thickness burns. Superficial partial-thickness burns extend into the dermis. These blistering wet-looking wounds will seep fluid and blanch with pressure. They heal within three weeks.

Deep partial-thickness burns will extend into the subcutaneous fatty layer. These burns have a waxy appearance and do not blanch with pressure. Blisters will easily rupture if touched. Healing time is greater than three weeks.

Full-thickness third-degree burns cause damage to all the layers of the skin. The burned skin looks waxy white, charred or leathery gray in color. These burns may cause little or no pain if the nerves are damaged. These burns will only heal at the skin edges and form scars unless skin grafting is done.

Each of these burns requires specific treatment. Never apply butter, oil, ice or ice water on burns because it can cause more damage. It is best not to apply any lotions or creams until a burn-type diagnosis is made.

Superficial burns require immediate soaking in cool water (50 degrees to 55 degreesF or 10 degrees to 13 degreesC) for at least 10 to 15 minutes. The cool water will prevent some of the burned tissue from dying and help ease the pain. Although application of antibiotic creams and salves like aloe vera will not speed healing, they may provide some wound comfort. Use a dry gauze bandage to cover the burn if it needs protection. Acetaminophen or ibuprofen can help control the pain.

Superficial partial-thickness or deep partial-thickness burns should soak in cool water for 15 to 20 minutes. If the burn is small, apply a cool wet clean cloth to it for a few minutes each day. Thereafter, apply the antibiotic cream or ointment prescribed by your doctor. Wash your hands with soap and water and/or use an alcohol gel disinfectant before any dressing change.

Cover the burn with a nonstick bandage like Telfa and hold it in place with gauze or tape. Never use mesh gauze to cover the wound because it will incorporate itself into the tissue and is very painful and damaging when removed. Make sure you are up-to-date on tetanus shots. Stronger prescription pain-relieving medication is available.

Do not break any blisters because this can lead to infection. Your doctor may have to drain the blisters that cover joint areas because they may restrict movement.

Infected burns usually become increasingly red, swollen and painful and form pus. Look for these signs when doing a daily dressing change and consult your doctor should this occur.

Ensure your fingernails are cut short because burns itch as they heal. The damaged skin is sensitive to sunlight for up to a year after the injury. Exposure to sunlight can cause a permanent dark tanned patch.

If any of these burns covers an area greater than 10 per cent of the total body surface or is on the face, hands, feet or genitals, see a doctor immediately.

Full-thickness burns require immediate hospitalization. Do not remove any clothing stuck to the burn and do not soak the burn in water. Remove loose clothing and jewelry.

Electrical burns may not show any skin damage but often cause serious internal injuries. Chemical burns should be washed with copious amounts of water. Remove any chemical-soaked clothing. Do not apply anything to the burn because of the risk of a chemical reaction. Both chemical and electrical burns require an emergency room evaluation.

Prompt treatment of burns can help reduce the extent of scarring and infection.

For more information, check the website http://www.findarticles.com/cf_dls/m3225/9_62/67051929/p1/article.jh tml

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Originally published in The Ottawa Citizen November 11, 2003
Original Title: Plaques are not trophies

October was National Psoriasis Awareness Month. Despite a press release from the Canadian Dermatological Association, the illness did not garner much press coverage.

Psoriasis fall into the category of common illnesses lost in the competitive din of common serious diseases. Two to five per cent of the world’s population suffers from this debilitating disease. Thirty-five percent of patients can identify a family history of the disease. A child with one parent with psoriasis can look forward to a 25 per cent chance of developing the disease and a 60 per cent chance if both parents suffer from it.

One million Canadians have psoriasis. It usually starts between the ages of ten to 40. Dr. Charles Lynde, dermatologist and president of the Canadian Dermatological Association states “Unless you are a patient suffering from the scaling, itching, pain and skin redness that characterizes psoriasis, the feelings of helplessness and frustration are hard to understand.”

Psoriasis is seen more often in alcoholics. Alcoholism is a significant risk factor for mortality among patients with psoriasis. The assumption is alcohol consumption may decrease the response to conventional treatment.

It has a variety of appearances and erupts on different body surfaces. It is an unpredictable illness that can flare for weeks to months followed by a period of quiescence.

Why does it occur? Normal surface skin cells shed every 28 days. Due to an immune system disturbance, the cells shedding time accelerates to every two or three days. This creates red, flaky itchy and often painful skin. The skin can become so severely cracked or split that secondary bacterial infections are a risk.

It has a major impact on the quality of life causing disabilities akin to diseases such as cancer and diabetes among others. Thirty per cent of psoriasis sufferers will have arthritic changes. Five to ten per cent will experience some degree of functional disability from arthritic change. The psychological effects include depression, low self-image and esteem, anxiety, feelings of hopelessness and suicide. Suicide rates are three times greater than the general population.

Psoriasis is a life-long disease. The areas of involvement include the knees, elbows, groin and genitals, back, arms, legs, palms and soles, face, scalp, body skin folds and nails. It is not contagious but requires vigilant follow-up to reduce and prevent the morbidity of relapses. The goal is to maintain a prolonged state of remission. Remission is seen in 25 per cent of patients.

Plaque psoriasis is a common form of the disease usually first appearing in young adults. Thick symmetrically distributed red plaques with sharp margins and white silvery scales appear on the arms, knees and scalp hair margin and range in size from one to ten centimeters.

A variant (flexural variant) appears in the armpits and under the breasts. These plaques are smooth, red and shiny.

Guttate psoriasis occurs in adolescents and adults. It appears as one centimeter “drop-like” lesions symmetrically distributed on the trunk and limbs.

Several localized forms appear on the palms and scalp. Palmoplantar psoriasis is characterized by the appearance of yellow to brown coloured sterile pustules on the palms of the hands or soles of the feet. It is commonly seen in middle aged females with a cigarette smoking history.

For some, scalp involvement is the disease’s only manifestation.

Nail changes occur in 50 per cent of psoriasis cases. Small pits and crumbling of the nail’s edge are common. A tan-brown motor oil-like discolouration appears in the nail (the “oil drop sign).

Certain medications will make psoriasis worse: beta blockers, lithium, and antimalarial drugs; angiotensin converting enzyme inhibitors (ACE) and non steroidal anti-inflammatory drugs (NSAIDs).

Other complications include arthritis of the hands and feet causing sausage-like swelling of the finger or toes joints (distal interphalangeal) adjacent to the nails, rheumatoid-like arthritic changes, erosion of the small bones of the hands and feet (mutilans arthritis) and ankylosing spondylitis/sacroiliitis.

The basis for the choice of treatment depends upon the severity of the illness. Mild plaque psoriasis can be treated with topical corticosteroids and emollients. Two newer treatments are available. Dovobet (a topical steroid with the vitamin D derivative calcipotriol) and Tazorac (tazarotene, a vitamin A derivative) are effective in mild to moderate psoriasis. Improvement occurs within one to four weeks.

Other options for moderate plaque psoriasis include potent topical steroids with or without tar and ultraviolet phototherapy. Widespread psoriasis requires phototherapy or more specialized systemic therapies best handled by dermatologists.

All these treatments continue to be refined and optimized to help more people with psoriasis live a normal life. Please consult your doctor to review the treatment that is best for you.

Further information is available at http://www.dermatology.ca and http://www.skincarephysicians.com/psoriasisnet/whatis.htm

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Originally published in The Ottawa Citizen June 24, 2003
Original Title: Poison Ivy

During the summer months, it is common to see people come in with peculiar linear or blotchy blistered red rashes. Welcome to poison ivy country.

Poison ivy was named in 1609 by adventurer, explorer and president of the British colony of Jamestown, Capt. John Smith. It belongs to the cashew family.

Found in areas of southern Canada and parts of the United States, it grows as a vine on trees or as a bush in grassy or bare areas. Often you will encounter it along the edges of roads, footpaths or fields, a new shopping mall or a housing subdivision where it does not have to compete with other vegetation. Hiking trails in and around Ottawa-Gatineau post poison ivy warnings.

Poison ivy is readily identifiable. The leaves grow on the stalk in groups of three. Their colouration starts as red in the spring, changing to shiny green in summer, then yellow, red or orange by the fall. Poisonous white, waxy clustered berries appear later in the season.

Poison ivy is related to poison oak (Pacific Northwest and western Canada) and poison sumac (eastern United States). However, these plants are shrubs and have seven to 13 leaves per stem, unlike poison ivy.

The sap (oleoresin) from the vine or shrub, and urushiol oil (from the Japanese, urushi meaning lacquer) are intensely irritating to the skin. One billionth of a gram (a nanogram) will cause a rash. An affected person’s average exposure is 100 nanograms. To put this natural irritant’s strength in perspective, seven grams (a quarter-ounce) would be enough to cause a rash for everyone on Earth.

The oleoresin can remain active on any surface, including dead plants, for up to five years. Collecting firewood over the winter can inadvertently include the poison ivy vine. Burning the vine will release the urushiol into the air leading to lung and eye irritation.

Poison ivy rash is not an infection but a chemical irritation. The fluid within the rash’s blisters does not contain the oleoresin and will not spread the rash. It will spread from person to person if the hands or clothing remains contaminated with oleoresin. Washing the oleoresin from the skin, clothing and surfaces eliminates the risk of contaminating others.

About 50 to 70 per cent of the population is allergic to urushiol, especially those with cashew allergies. The rash appears 24 to 48 hours after contact with the resin. It quickly becomes red and intensely itchy. Blisters can form. Often, the rash appears in streaks where the vine has scratched the skin.

The rash usually resolves one to two weeks after exposure. Some people with no previous exposure to poison ivy will develop the rash seven to 10 days after exposure. Frequent exposure to poison ivy increasingly stimulates the allergic response and the rate of rash and blister formation.

There is a 10-minute window of opportunity after exposure when thorough soap and water washing of the skin can minimize the chance of a rash. Remove any clothing contaminated by the oil, and wash it thoroughly, being careful not to touch the clothes with your bare hands.

Treatment options depend on the severity and discomfort of the rash. The use of antihistamines, cool compresses, Aveeno colloidal oatmeal baths and topical steroid creams can limit mild to moderate reactions.

Do not intentionally break the blisters. They act as a protective covering for the healing skin underneath them. It can lead to secondary bacterial infections, complicating treatment and potentially worsen scarring. Consult your doctor if large blisters form on your hands. It may be necessary to drain the blisters to allow more freedom of movement, reduce hand stiffness and loss of function.

Wet-to-dry dressings on oozing blisters can dry them out so you can apply steroid creams. Your pharmacist can help prepare a Burow’s solution. Apply this solution to a single thin cotton sheet or fabric and apply it to the skin. Allow the fabric to dry over 30 minutes. Repeat the procedure several times. For those who suffer extensive skin damage, your doctor may prescribe a short-term course of oral steroids. The rash usually resolves within two to four weeks. Prevention is a matter of avoiding the plant. Pets — especially dogs — can pick up the resin on their fur, so be mindful after Greenbelt excursions.

Resources:

http://poisonivy.aesir.com/;
http://ncnatural.com/wildflwr/obnxious.html;
http://www.aad.org/pamphlets/PoisonIvy.html

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1. Burns Require Specific Treatment
2. How to avoid mosquito bites – DEET Repellents Must Be Used With Care
3. Childhood rashes hard to diagnose at first

Originally published in The Ottawa Citizen April 29, 2003

Original Title: The big gaping maw

As warmer weather approaches, children will be spending more time playing outdoors. So will dogs.

Although there are dog leash laws in Ottawa and the majority of dog owners are responsible, dog bites remain the most common animal bite seen in our hospitals. The Canada Safety Council estimates there are 460,000 dog bites in Canada every year, almost half of them involving children.

The Canadian Hospitals Injury Reporting and Prevention Program states animal bite injuries account for one per cent of all emergency room visits, with dogs accounting for 85 per cent of all these wounds.

Boys five to nine years old sustain the most dog bites –they account for 28.5 per cent of all bitten people. And almost one-third of the time, bites occur between 4 p.m. and 8 p.m. during summertime.

The victim usually knows the dog. Eighty-five per cent of all dog and cat bites come from the family’s or a neighbour’s pet. Thirty-four per cent of attacks occur at the victim’s home and 30 per cent at a friend’s house. Provoking the animal accounts for half of all bite attacks.

Our children are more susceptible to serious injury because they are lower to the ground. Head, face and neck bites account for 70 per cent of the cases. Forty per cent of all bites in children are facial.

Over half of all attacks were minor requiring little treatment. A third needed medical follow-up after leaving the emergency department and one in 20 required admission to hospital.

The wound care for dog and cat bites vary. Dog bites cause lacerations, punctures and crush injuries. Cat bites commonly puncture the skin. Cat bite punctures have a high risk of bacterial infection; three to 18 per cent of dog bites become infected versus 28 to 80 per cent of cat bites.

There are several initial steps to care for a dog or cat bite. First, use soap and water and gently wash the wound.

Use a clean towel when applying direct pressure to stop the bleeding of the injured part. Apply a sterile bandage to the wound.

To reduce swelling and prevent infection, try to keep the injured part raised above the level of the heart.

Consult your doctor no later than eight to twelve hours after the bite injury for an evaluation. It may require oral antibiotic therapy. Report the incident.

Cat bites (not scratches) warrant a visit to your doctor because of their high risk of infection. Deep or gaping lacerations, bites to the hand, foot or head or any signs of infection like swelling, worsening pain, a spreading area of redness, fever or oozing of pus from the wound require immediate attention. Seek medical advice and treatment if the bleeding does not stop despite 15 minutes of direct firm pressure or if you suspect nerve damage, broken bones or a severe soft tissue crush injury.

People with underlying medical conditions that compromise their body’s wound healing capability such as cancer, lung disease, diabetes, liver disease or hepatitis, AIDs or other conditions that weaken the ability to fight infection should consider every bite as serious and warranting medical attention.

Your doctor’s approach to any bite injury is to ascertain the risk of infection, clean and remove any damaged tissue (debride the wound) if necessary and to determine whether to stitch it closed or leave it open to heal. The doctor will explore the wound to determine if there is damage to deeper structure like nerves and tendons.

Deep penetrating cat bites through joint spaces, bones or tendons, bites to the face, hands, feet and genitalia and wounds requiring surgical repair usually need an oral antibiotic to prevent infection.

Antibiotic ointments like Fucidin and Bactroban work well for dog and cat bite wounds with low risk of infection. Get a tetanus vaccine booster if your last one was more than five years ago. It is best to schedule a follow-up visit one to two days after the initial assessment.

If the injury is severe, the wound fails to heal or the infection spreads despite oral antibiotics, you will likely require hospitalization. In these cases, intravenous antibiotics and an assessment from a plastic surgeon is usually in order.

Rabies shots are rarely required for dog and cat bites. The decision to vaccinate against rabies is a concern of the public health department and the medical officer of health.

Preventing animal bites continues to be an area in need of improvement. Young children need constant supervision in the presence of any pet. Animals that are eating, fighting amongst themselves or appear sick should be left alone.

When choosing a dog, pick a family-friendly dog. Veterinarians, professional dog breeders or dog trainers are an excellent resource.

© Dr. Barry Dworkin 2003

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1. How to avoid mosquito bites – DEET Repellents Must Be Used With Care
2. Skin infections need specific treatments
3. Hand infections need immediate attention

Originally published in The Ottawa Citizen October 15, 2002
Original Title: Daycare Part III: A little red in the face

Part I – Why children fight one cold after another
Part II – Children’s eye diseases spread quickly

What are the common childhood rashes seen in the school and daycare setting? Initially, many rashes can look the same, which can sometimes make identification difficult. Rashes eventually branch off in their own direction within a day or two prompting the doctor to say “Aha! I knew what it was happening all along!” This is something akin to what your investment broker says to you now.

Roseola is a viral rash usually seen in children between six and 24 months of age. These children do not appear ill but can have a low-grade fever for a few days. In rare cases, children can develop high fever and febrile seizures. Once the fever breaks, the rash appears as small red spots scattered on the face and body that last a day or two. It is not very infectious and there is no specific treatment.

Hand, Foot and Mouth disease most often affects young children but can appear at any age. It is an infectious viral illness spreading from person to person by air or touch. It occurs more commonly in the summer and fall. It will incubate for ten to 14 days before the start of symptoms. Although usually not severe, it does cause fever, headaches, loss of appetite, diminished activity and energy levels, sore throat and a particular rash.

Small red spots with a blister on top appear on the hands and feet and sometimes on other body parts. There can be painful mouth ulcers. The rash lasts seven to ten days. Children remain infectious one to two weeks after the onset of the illness. There is no specific treatment. Children can return to school or daycare once they feel up to participating in normal activities.

Fifth disease commonly referred to as Slapped Cheeks Syndrome occurs in school-aged children. One to four days before the onset of rash, the child may have had a cold-like illness. Some children will have a headache, sore throat, runny nose, itchiness, nausea, diarrhea and vomiting, joint pain and sore eyes. The range of occurrence of these symptoms runs on average between zero to 50 percent.

It starts as a dark red rash on the cheeks that looks like the face was slapped. By the time the rash develops, the child usually feels better. A rosy red lacy rash appears on the arms and body that can come and go over a period of one to three weeks. There is no specific treatment. They are no longer infectious once the rash appears. Children can return to school when they feel better.

Chicken pox, despite the popular misconception, is not a benign disease. Caused by the Varicella Zoster virus, its complications include skin and soft tissue infection, ear, eye, nose and throat infections, serious bacterial infections like necrotizing fasciitis (“flesh eating disease”), pneumonia, encephalitis and meningitis. In Canada, 2000 children were admitted to hospital last year and 12 died.

Chicken pox has an incubation period of eight to 13 days after viral exposure. It spreads through the air and by direct contact with the blisters.

It starts with a fever for the first two days. Thereafter the classic “fried egg” blisters appear (a red circular spot with a blister in the centre) on the skin. An average of 350 blisters will erupt on the child’s body.

If you think the child has chicken pox or if indeed they do, isolation from pregnant women who have never had chickenpox is important because the virus can damage the fetus. There is no danger to pregnant women who are immune to the virus.

Do not give aspirin (Acetylsalicylic Acid (ASA)) or any products that contain ASA to a child with chicken pox. They can develop Reye’s syndrome that can damage the liver and brain. Use Acetaminophen (Tylenol or Tempra) instead.

Good gentle skin hygiene will help prevent bacterial infections of the pox blisters. Scrubbing the skin can promote infection and scarring. Antihistamines (Claritin, Benadryl) and Aveeno bath powder can help relieve the itch. Calamine lotion is ineffective.

After a chicken pox infection, the virus can lie dormant in the body for years. Once reactivated, it will cause Shingles, a large painful blistered rash on a segment of your body or face with its own set of painful and damaging complications.

What can we do to prevent some of the illnesses reviewed over these past three weeks? Good hygiene and disinfecting toys reduces contagion. However, this is a Herculean task in a room full of toddlers and young children. Some diseases warrant isolating the child during their contagious period. There are vaccines available that can reduce the risk of some of these diseases.

Varivax will protect children from chicken pox. Over 20 million doses and 28 years of experience show long-lasting immunity. Ninety-five percent of children will become immune six weeks after vaccination.

Prevnar will reduce the rate of ear infections and pneumonia caused by the bacteria Streptococcus pneumoniae. It is the most common cause of ear infections, pneumonia and meningitis in infants and toddlers. Menjugate vaccine will protect children from another type of meningitis.

All children that follow the routine vaccination schedule receive the Pentacel vaccine. One component of it protects infants and children against the bacteria Hemophilus influenzae that causes ear infections and pneumonia.

Your doctor can provide more information on your next well-child visit. The only thing infectious in your child should be their smile. May they all be happy and healthy.

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